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Accepted Manuscript

2016 ACC Lifelong Learning Competencies for General Cardiologists: A Report from

the ACC Competency Management Committee

Eric S. Williams, MD, MACC, Chair, Writing Committee Member, Jonathan L.

Halperin, MD, FACC, Co-Chair, Writing Committee Member, James A. Arrighi, MD,

FACC, Writing Committee Member, Eric H. Awtry, MD, FACC, Writing Committee

Member, Eric R. Bates, MD, FACC, Writing Committee Member, Salvatore Costa,

MD, FACC, Writing Committee Member, Rosario Freeman, MD, MS, FACC, Writing

Committee Member, John A. McPherson, MD, FACC, Writing Committee Member,

Lisa A. Mendes, MD, FACC, Writing Committee Member, Thomas Ryan, MD, FACC,

Writing Committee Member, Chittur A. Sivaram, MBBS, FACC, Writing Committee

Member, Howard H. Weitz, MD, FACC, Writing Committee Member

PII: S0735-1097(16)00606-9

DOI: 10.1016/j.jacc.2016.02.011

Reference: JAC 22247

To appear in: Journal of the American College of Cardiology

Please cite this article as: Williams ES, Halperin JL, Arrighi JA, Awtry EH, Bates ER, Costa S,

Freeman R, McPherson JA, Mendes LA, Ryan T, Sivaram CA, Weitz HH, 2016 ACC Lifelong Learning

Competencies for General Cardiologists: A Report from the ACC Competency Management Committee,

Journal of the American College of Cardiology (2016), doi: 10.1016/j.jacc.2016.02.011.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to

our customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Please

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http://dx.doi.org/10.1016/j.jacc.2016.02.011http://dx.doi.org/10.1016/j.jacc.2016.02.011


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2016 ACC Lifelong Learning Competencies for General Cardiologists: AReport from the ACC Competency Management Committee

Writing Committee MembersEric S. Williams, MD, MACC, Chair

Jonathan L. Halperin, MD, FACC, Co-Chair

James A. Arrighi, MD, FACC John A. McPherson, MD, FACC

Eric H. Awtry, MD, FACC Lisa A. Mendes, MD, FACCEric R. Bates, MD, FACC Thomas Ryan, MD, FACC

Salvatore Costa, MD, FACC Chittur A. Sivaram, MBBS, FACC

Rosario Freeman, MD, MS, FACC Howard H. Weitz, MD, FACC

ACC Competency Management CommitteeEric S. Williams, MD, MACC, Chair

Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Jeffrey T. Kuvin, MD, FACC

Eric H. Awtry, MD, FACC Joseph E. Marine, MD, FACC

Eric R. Bates, MD, FACC John A. McPherson, MD, FACC

John E. Brush, JR, MD, FACC Lisa A. Mendes, MD, FACC

Salvatore Costa, MD, FACC Chittur A. Sivaram, MBBS, FACC

Lori Daniels, MD, MAS, FACC Robert L. Spicer, MD, FACC

Susan Fernandes, LPD, PA-C Andrew Wang, MD, FACC, FAHA

Rosario Freeman, MD, MS, FACC Howard H. Weitz, MD, MACP, FACC

Sadiya S. Khan, MD

The document was approved by the American College of Cardiology Board of Trustees and Executive Committee inFebruary 2016. For the purpose of transparency, disclosure information for the ACC Board of Trustees, the board ofthe convening organization of this document, is available at: http://www.acc.org/about-acc/leadership/officers-and-trustees.

The American College of Cardiology requests that this document be cited as follows: Williams ES, Halperin JL,Arrighi JA, Awtry EH, Bates ER, Costa S, Freeman R, McPherson JA, Mendes LA, Ryan T, Sivaram CA, WeitzHH. 2016 ACC lifelong learning competencies for the general cardiologist: a report of the ACC Competency

Management Committee. J Am Coll Cardiol 2016; XX:xxx-xx.

Copies: This document is available on the World Wide Web site of the American College of Cardiology(www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820,

email reprints@elsevier com


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Table of ContentsPreamble ................................................................................................................................................. 3

1. Introduction ..................... ........................ ......................... ....................... ......................... ................... 5

1.1. Document Development Process ............................................ ......................... ...................... ........ 5

1.1.1. Writing Committee Organization ......................... ....................... ......................... ................... 5

1.1.2. Document Development and Approval ............................................ ...................... ................. 51.2. Background and Scope.................................................................................................................. 6

Table 1. Framework of Cardiovascular Competencies for Lifelong Learning .................................... 6

Table 2. Entrustable Professional Activities for Subspecialists in Cardiovascular Disease................. 7

1.2.1. Lifelong Learning Competencies ......................... ....................... ......................... ................... 7

Table 3. ACGME Core Competencies ...................... ......................... ......................... ...................... 8

1.2.2. Assessment Tools ........................ ........................ ....................... ......................... ................... 8

1.2.3. Research and Scholarly Activity ..................... ......................... ...................... ......................... 9

2. Clinical Competencies ..................... ......................... ...................... ......................... ......................... ... 9

Table 4. Ambulatory, Consultative, and Longitudinal Cardiovascular Care Lifelong Learning

Competencies ................................................................................................................................ 10

Table 5. Cardiovascular Disease Prevention Lifelong Learning Competencies................................ 11

Table 6. ECG/Ambulatory ECG Lifelong Learning Competencies ................................................. 12

Table 7. Exercise ECG Testing Lifelong Learning Competencies ................................................... 13

Table 8. Echocardiography Lifelong Learning Competencies ......................................................... 15

Table 9. Nuclear Cardiology Lifelong Learning Competencies ....................................................... 16

Table 10. Cardiovascular Computed Tomography Lifelong Learning Competencies ........ ........... ... 17

Table 11. Cardiovascular Magnetic Resonance Lifelong Learning Competencies ........................... 18

Table 12. Invasive Cardiology Lifelong Learning Competencies .................................................... 19

Table 13. Stable Ischemic Heart Disease Lifelong Learning ............................... ...................... ...... 20

Table 14. Acute Coronary Syndromes Lifelong Learning Competencies ........................................ 22


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Table 21. Adults With Simple Congenital Heart Disease [Atrial Septal Defects, Ventricular Septal

Defects, Patent Ductus Arteriosus, Pulmonary Stenosis, Bicuspid Aortic Valve, Coarctation]

Lifelong Learning Competencies ..................... ......................... ......................... ...................... ...... 33

Table 22. Adults With Complex Congenital Heart Disease [Ebstein’s Anomaly, Tetralogy of Fallot,

Complex Cyanotic Congenital Heart Disease, Transposition of the Great Arteries, Single Ventricle

Physiology/Fontan] Lifelong Learning Competencies ....................... ...................... ....................... 34

Table 23. Additional Professional Behavior Competencies Relevant to All Clinical Areas ........... ... 34

3. Leadership and Administrative Competencies ...................... ......................... ...................... ............... 35

Table 24. Leadership and Administrative Competencies ....................... ......................... ................. 36

References ........................ ...................... ......................... ......................... ...................... ....................... 37

Appendix 1. Author Relationships With Industry and Other Entities (Relevant) ..................................... 39

Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) ................................. 41

Appendix 3. ECG Core Competencies: Pattern and Arrhythmia Recognition ......................................... 43

Preamble

Beginning with publication of the first Core Cardiovascular Training Statement (COCATS) in 1995, the

American College of Cardiology (ACC) has played a central role in defining the knowledge, experiences,

skills, and behaviors expected of adult clinical cardiologists upon completion of fellowship training.

Subsequent updates have incorporated major advances and revisions—both in structure and content—

including, most recently, a transition to training based on competency outcomes under the 6 domains

promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and the American

Board of Medical Specialties, and endorsed by the American Board of Internal Medicine (ABIM). Many

hospital systems now use the 6-domain structure as part of medical staff privileging, professional

competence assessments, and peer review. The ACC endorses a similar structure to align the

competencies and lifelong learning objectives that all practicing cardiologists are expected to maintain

throughout their careers.


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heart failure, and adult congenital heart disease. The Advanced Training Statements also describe key

experiences and outcomes necessary to maintain or expand competencies during practice.

A key feature of competency-based training and performance is an outcome-based evaluation

system. All ACC competence and training statements therefore include examples of tools that can be used

to assess achievement of the individual components of competency. Recommendations in these

statements are based on available evidence and, where evidence is lacking, reflect expert opinion. Thewriting committees reflect the diversity of clinical cardiology, and typically include content experts,

general cardiology and sub-subspecialty training program directors, practicing cardiologists, and early-

career representatives. All documents are subject to rigorous peer review. Recommendations are intended

to guide the assessment of competence of cardiovascular care providers beginning independent practice as

well as those undergoing periodic review to help ensure that competence is maintained.

This Competency Statement complements the basic training in cardiovascular medicine required

of all trainees during the standard 3-year cardiovascular fellowship by focusing on the core competencies

reasonably expected of all general cardiologists throughout the span of their careers. It also identifies

certain aspects of cardiovascular medicine that exceed core expectations and may be maintained or

achieved by some general cardiologists, depending on their background and practice focus. This

document provides examples of appropriate measures for assessing competence in the context of lifelong

learning.

Writing Committee members volunteered their time for this effort which was supported

exclusively by the ACC without commercial involvement. Meetings and conference calls were

confidential and attended only by committee members. To ensure transparency, comprehensive

healthcare-related disclosure information, including relationships with industry and other entities (RWI)

not pertinent to this document, is posted online(http://jaccjacc.acc.org/Clinical_Document/LL_Comps_Comprehensive_Author_RWI_Table--2-9-

2016.pdf). Disclosure information for the ACC Competency Management Committee is available at

http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-

forces, as well as the ACC disclosure policy for document development at


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1. Introduction

1.1. Document Development Process

1.1.1. Writing Committee Organization

The writing committee was selected by the American College of Cardiology (ACC) and included

cardiovascular training program directors, cardiology clinic directors, early career cardiovascular disease

prevention experts, experienced specialists representing both the academic and community-based practice

settings, and physicians experienced in defining and applying training standards according to the core

competencies structure promulgated by the Accreditation Council for Graduate Medical Education

(ACGME) and American Board of Medical Specialties (ABMS) and endorsed by the American Board of

Internal Medicine (ABIM). The ACC determined that relationships with industry or other entities were

not relevant to the creation of a general cardiology competence statement, and employment and affiliation

information for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with

disclosure reporting categories. Comprehensive disclosure information for all authors, including RWI not

deemed relevant to this writing effort, is available online at

(http://jaccjacc.acc.org/Clinical_Document/LL_Comps_Comprehensive_Author_RWI_Table--2-9-

2016.pdf).

1.1.2. Document Development and Approval

The writing committee initially adapted the 20 competency tables in COCATS 4 (1-16) to align with the

lifelong learning environment that defines the practice of general clinical cardiology. Individual tables

were then sent to the corresponding COCATS authoring groups for review and commentary. The Writing

Committee reviewed this feedback and revised the tables to ensure applicability to general cardiologists in

practice, including competencies pertinent to practice focus, and establish continuity across all tables. The

Writing Committee then compiled the tables, aggregated a common set of professional behavior

competencies (Systems-Based Practice, Practice-Based Learning and Improvement, Interpersonal and

C i i Skill d P f i li ) d dd d L d hi d Ad i i i i i


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The final document was approved by the Writing Committee, ACC Competency Management Committee

and ACC Lifelong Learning Oversight Committee, and ratified by the ACC Board of Trustees and

Executive Committee in February 2016. This document is considered current until the ACC Competency

Management Committee revises, replaces, or withdraws it.

1.2. Background and Scope

In 2010, the ACC began an ambitious initiative to delineate: 1) the core clinical competencies essential

for trainees to attain during a 3-year cardiovascular fellowship (COCATS 4), and 2) the aligned

competencies that patients and accrediting bodies can reasonably expect clinical cardiologists in practice

(e.g., 10 years) to acquire, maintain, or enhance through lifelong learning. Key features of this outcomes-

based curriculum include the 6-domain structure promulgated by the ACGME. The cardiovascular

competencies, organized in a topical format (Table 1), provide a structure for the ACC learning pathways

and underpin all ACC educational activities.

Table 1. Framework of Cardiovascular Competencies for Lifelong Learning

1. Ambulatory, Consultative, and Longitudinal Cardiovascular Care2. Cardiovascular Disease Prevention3. ECG and Ambulatory ECG

4.

Exercise ECG5. Echocardiography6. Nuclear Cardiology7. Cardiovascular Computed Tomography8. Cardiovascular Magnetic Resonance9. Invasive Cardiology10. Stable Ischemic Heart Disease11. Acute Coronary Syndromes12. Valvular Heart Disease13. Heart Failure14.

Pericardial Disease15. Vascular Medicine16. Arrhythmias and Electrophysiology17. Critical Care Cardiology18. Adult Congenital Heart Disease19. Additional Professional Behavior Relevant to All Clinical Areas20 L d hi d Ad i i t ti


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(EPAs) that patients and the public can reasonably expect all competent clinical cardiologists to be able to

perform (Table 2).

Table 2. Entrustable Professional Activities for Subspecialists in Cardiovascular Disease

• Cardiovascular Consultation – evaluate, diagnose, and develop treatment plans for patients with known,

suspected, or at risk of developing cardiovascular disease

• Acute Cardiac Care – manage patients with acute cardiac conditions

• Chronic Cardiovascular Disease Management – manage patients with chronic cardiovascular diseases

• Cardiovascular Testing – appropriately utilize cardiovascular diagnostic testing

• Disease Prevention and Risk Factor Control – implement disease prevention and risk factor control

measures, addressing comorbidities

• Team-Based Care – work effectively to promote and coordinate interdisciplinary, patient-centered care

• Lifelong Learning – engage in lifelong learning to maintain and enhance knowledge and skills

1.2.1. Lifelong Learning Competencies

The lifelong learning competencies for general cardiologists are organized using the 6 domains

promulgated by ACGME/ABMS and endorsed by ABIM (see Table 3). Section 2 focuses on clinical

competencies, encompassing the Medical Knowledge and Patient Care and Procedural Skill competencies

related to the 18 clinical areas identified in Table 1 (see Tables 4 to 22). These competencies are unique to

each clinical area. In addition, Section 2 includes a common set of professional behavior competencies

that pertain to all clinical areas (see Table 23), describing competencies for Systems-Based Practice,

Practice-Based Learning and Improvement, Interpersonal and Communication Skills, and

Professionalism. Section 3 of the document focuses on leadership and administrative competencies thatpertain to general clinical cardiologists, highlighting leadership, operational skills, professional identity,

and personal balance (see Table 24).


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Table 3. ACGME Core Competencies

• Patient Care that is compassionate, appropriate, and effective for treating health problems and promoting

health.

• Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g.,

epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

• Practice-Based Learning and Improvement that involve investigation and evaluation of their own patient

care, self-appraisal, and assimilation of scientific evidence, and improvements in patient care.

• Interpersonal and Communication Skills that result in effective information exchange and teaming with

patients, their families, and other health professionals.

• Professionalism as manifested by a commitment to carrying out professional responsibilities, adherence to

ethical principles, and sensitivity to a diverse patient population.

• Systems-Based Practice as manifested by actions that demonstrate an awareness of and responsiveness to

the larger context and system of health care and the ability to effectively call on system resources to provide

care that is of optimal value.

These minimum general competencies were endorsed by the ACGME in February 1999 (www.acgme.org) andall Residency Review Committees and Institutional Review Committees were to include this minimum languagein their respective Program and Institutional Requirements by June 2001. The definitions are available athttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043418/ .

ACGME = Accreditation Council for Graduate Medical Education.

1.2.1.1. Distinction Between Competencies Expected of All Clinical Cardiologists and

Those Required Based on the Focus of Practice

All tables distinguish competency components expected of all clinical cardiologists (left column) from

those expected of selected clinical cardiologists based on background, specialized knowledge, skills,

experience, and practice focus (right column). It is important to note that the practice-focused designation

in this document does not refer to the advanced competencies of cardiovascular sub-subspecialties – suchas interventional cardiology, cardiac electrophysiology, advanced heart failure, and adult congenital heart

disease – that require training beyond the standard training common to all clinical cardiologists. Rather,

the practice-focused competencies in this document parallel, and are analogous to, the Level II

competencies defined in COCATS 4


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review of practice or hospital data, performance assessment and improvement programs, and facilitated

self-reflection. For procedural or diagnostic laboratory activities, assessment tools may include registry

and/or hospital data, appropriate use criteria, and metrics developed by professional organizations. Patient

surveys and multisource (360˚) evaluations in hospital or practice environments can provide information

about outcomes, communication skills, and professionalism. The ABIM is evolving a portfolio of

professional development offerings, including components designed to facilitate maintenance and

assessment of competency.

1.2.3. Research and Scholarly Activity

The topic areas in Table 1 define the core clinical, leadership, and administrative competencies for

practicing cardiologists. Scholarly activity and clinical research are also important in lifelong learning and

professional competency. All physicians should have the skills to assess new research findings andappropriately incorporate new diagnostic and treatment modalities in patient care. In addition, a scholarly

approach is required to evaluate evidence, address clinical questions, and enhance outcomes through

literature review, including at the point of care. Knowledge should also be maintained and enhanced

through regular reading of journals and other sources of reliable information and through attending

scholarly scientific meetings and professional congresses. Referral of patients for participation in well-

designed clinical trials is encouraged for both academic and nonacademic cardiologists.

2. Clinical Competencies


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Table 4. Ambulatory, Consultative, and Longitudinal Cardiovascular Care Lifelong Learning

Competencies

Competency ID Medical KnowledgeAll Clinical

Cardiologists

Selected

Cardiologists

Based onPractice

Focus

L-AMB-MK1 Know the major cardiovascular risk stratification tools and principles of

primary and secondary prevention of cardiovascular disease.

X

L-AMB-MK2 Know the roles of genetics, family history, and environmental and lifestyle

factors in the development and clinical course of cardiovascular disease.

X

L-AMB-MK3 Know the effects of age on cardiovascular function, response to

medications, and risks of diagnostic and therapeutic procedures.

X

L-AMB-MK4 Know the roles of l ifestyle, activity level, body mass, nutrition, and alcohol

and recreational drug use in patients with and at risk of cardiovascular

disease.

X

L-AMB-MK5 Know guideline recommendations for evaluation and management of

hypertension, diabetes, and dyslipidemia in diverse patient populations.

X

L-AMB-MK6 Know the treatment options to facilitate smoking cessation and theirlimitations.

X

L-AMB-MK7 Know the roles of stress, anxiety, and depression in patients with known or

suspected cardiovascular disease.

X

L-AMB-MK8 Know the differential diagnosis of chest pain and the features distinguishing

its various etiologies.

X

L-AMB-MK9 Know the differential diagnosis of palpitation, lightheadedness andsyncope, and the features distinguishing the various etiologies.

X

L-AMB-MK10 Know the differential diagnosis of dyspnea and the features distinguishing

its various etiologies.

X

L-AMB-MK11 Know the differential diagnosis of peripheral edema and the features

distinguishing its various etiologies.

X

L-AMB-MK12 Know the roles of renal, hepatic, pulmonary, hematologic, rheumatologic,

and endocrine disorders in the development of cardiovascular disease and

responses to treatment.

X

L-AMB-MK13 Know the clinical pharmacology of cardiovascular medications, their

interactions with other medications generally, in special populations, and in

patients with relevant comorbidities.

X

L-AMB-MK14 Know the potential cardiovascular toxicity and side effects of the major

classes of drugs used for management of patients with common medical

X


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L-AMB-MK19 Know the principles of and indications for palliative care in patients with

heart disease.

X

Patient Care and Procedural SkillsAll

Practice

Focused

L-AMB-PC1 Skills to effectively and efficiently perform an initial outpatient

cardiovascular consultation and establish a differential diagnosis.

X

L-AMB-PC2 Skills to appropriately utilize diagnostic testing for both initial diagnosis

and follow-up care of patients with cardiovascular disease.

X

L-AMB-PC3 Skills to integrate clinical information and test results to assess risk,establish diagnosis, and formulate treatment and follow-up for patients with

cardiovascular disease.

X

L-AMB-PC4 Skills to identify patients with acute cardiovascular disorders or high-risk

states who require immediate treatment and/or hospitalization and to

prioritize management steps in patients with complex or multicomponent

illness.

X

L-AMB-PC5 Skills to establish an effective treatment regimen and monitor for side

effects, intolerance or nonadherence, and assure patient safety.

X

L-AMB-PC6 Skills to assess the cardiovascular risks associated with recreational and/or

competitive sports, physically demanding occupations, and other vigorous

physical activities, and to counsel patients about levels of physical activity

appropriate to their cardiovascular health status in the context of disease

prevention, rehabilitation, enhancement of functional capacity and quality

of life, and promotion of longevity.

X

L-AMB-PC7 Skill to effectively manage patients with chronic ischemic heart disease,

hypertension, heart failure, and peripheral artery disease.

X

L-AMB-PC8 Skills to coordinate ambulatory and longitudinal follow-up care and

facilitate transitions of care from hospital to ambulatory or intermediate-

care settings for patients with cardiovascular disease.

X

L-AMB-PC9 Skill to provide preoperative risk assessment for patients with

cardiovascular disease undergoing noncardiac surgery.

X

Table 5. Cardiovascular Disease Prevention Lifelong Learning Competencies


Cardiologists

Selected

CardiologistsBased on

PracticeFocus

L-PREV-MK1 Know the structure of normal arteries and the basic vascular biology of X


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L-PREV-MK7 Know the effects of diabetes mellitus, obesity, hypertension, lipiddisorders, physical inactivity, and tobacco use on the development andprogression of atherosclerosis and the corresponding treatment strategies.

X

L-PREV-MK8 Know the incremental benefit of additional screening methods (includingbiomarkers, coronary calcification, carotid intima-media thickness, andankle-brachial index) over a traditional risk-based approach to assesssubclinical atherosclerosis.

X

L-PREV-MK9 Know the principles of nutrition and obesity assessment and management,including the roles of pharmacotherapy and bariatric surgery.

X

L-PREV-MK10 Know the behavioral and psychosocial factors that contribute tocardiovascular disease and the principles of management.

X

L-PREV-MK11 Know the principles of exercise physiology and roles of physical activitycounseling and cardiac rehabilitation.

X

L-PREV-MK12 Know the effects of systemic diseases (including renal, hepatic,inflammatory, and autoimmune disorders) and their treatment oncardiovascular disease.

X

L-PREV-MK13 Know the adverse effects of sleep apnea on the incidence and control ofhypertension, atrial fibrillation and other arrhythmias, heart failure, and

atherosclerosis.

X

L-PREV-MK14 Know the indications for noninvasive screening for carotid artery disease,abdominal aortic aneurysm, and peripheral artery disease.

X

L-PREV-MK15 Know the impact of pregnancy and hormonal treatment for reproductivedisorders on cardiovascular risk.

X

L-PREV-MK16 Know the pharmacology, indications, contraindications, risks, andinteractions of medications commonly used for prevention and therapy ofcardiovascular disease (e.g., antithrombotic, antihypertensive, lipid-lowering, diabetes management, and tobacco cessation agents).

X

Patient Care and Procedural Skills All PracticeFocused

L-PREV-PC1 Skill to perform global risk assessment and appropriately utilize diagnostictesting in patients with or at risk of cardiovascular disease.

X

L-PREV-PC2 Skill to evaluate a patient’s family history and appropriately recommendfamily screening.

X

L-PREV-PC3 Skill to identify patients with common systemic disorders, such asobstructive sleep apnea and thyroid conditions, that affect cardiovasculardisease diagnosis and treatment.

X

L-PREV-PC4 Skill to implement and prescribe lifestyle approaches for prevention and

treatment of patients with hypertension, dyslipidemia, tobacco use, obesity,and diabetes mellitus.

X

L-PREV-PC5 Skill to evaluate and manage hypertensive cardiovascular disease,including treatment-resistant hypertension.

X

L-PREV-PC6 Skills to assess physical activity patterns and exercise capacity in patientswith or at risk of cardiovascular disease and provide counseling and

i i ti i l di h th d h t b i

X


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L-TEST-ECG-MK3 Know the normal values for electrical axis and ECG intervals and voltage. X

L-TEST-ECG-MK4 Know the anatomy of the specialized conducting tissue and the spread ofexcitation in the conduction system and myocardium.

X

L-TEST-ECG-MK5 Know the mechanisms of re-entry, automaticity, and triggered activity incardiac arrhythmias.

X

L-TEST-ECG-MK6 Know the types and mechanisms of aberrant cardiac conduction. X

L-TEST-ECG-MK7 Know capture and fusion complexes and the ECG criteria for distinguishingsupraventricular arrhythmias with aberrancy, accessory pathway conduction,pacing, and artifact from ventricular arrhythmias.

X

L-TEST-ECG-MK8 Know the concepts and ECG manifestations of concealed conduction and exitblock.

X

L-TEST-ECG-MK9 Know the characteristic ECG patterns of key clinical diagnoses. (SeeAppendix 3.)

X

L-TEST-ECG-MK10 Know the ECG patterns commonly seen in trained athletes and the challengesof distinguishing normal from abnormal findings.

X

L-TEST-ECG-MK11 Know the indications for and limitations of continuous ambulatory (Holter)and intermittent (event) ECG recordings.

X

Patient Care and Procedural Skills All Practice

FocusedL-TEST-ECG-PC1 Technical skill to record and interpret standard 12-lead ECG tracings and to

incorporate the findings in patient care.X

L-TEST-ECG-PC2 Skill to identify normal ECG patterns, variants, and artifacts (including leadmisplacement).

X

L-TEST-ECG-PC3 Skills to identify and interpret ECG signs of atrial abnormalities and right andleft ventricular hypertrophy or enlargement.

X

L-TEST-ECG-PC4 Skills to identify and interpret intraventricular conduction delay or blockincluding aberrant conduction abnormalities.

X

L-TEST-ECG-PC5 Skills to identify and interpret atrioventricular dissociation. XL-TEST-ECG-PC6 Skill to identify first-degree, second-degree (types I, II, and 2:1), and third-degree atrioventricular block.

X

L-TEST-ECG-PC7 Skills to identify the ECG patterns and localization of myocardial ischemiaand infarction.

X

L-TEST-ECG-PC8 Skill to identify the ECG patterns associated with electrolyte imbalance,metabolic abnormalities, and drug effects.

X

L-TEST-ECG-PC9 Skill to identify non-specific QRS and ST-T wave abnormalities. X

L-TEST-ECG-PC10 Skill to identify atrial, atrioventricular, nodal, and ventricular arrhythmias. X

L-TEST-ECG-PC11 Skill to integrate ECG findings into the clinical assessment and managementof patients with known or suspected heart disease. X

L-TEST-ECG-PC12 Skill to select and interpret ambulatory ECG recordings and integrate thefindings in the evaluation and management of patients with known orsuspected heart disease.

X

L-TEST-ECG-PC13 Skills to identify ECG patterns associated with normal and abnormalpacemaker function and consult an electrophysiologist when advanced

X


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L-TEST-STRESS-MK3 Know the concept of metabolic equivalent (MET) and estimation of intensityfor various modes of exercise.

X

L-TEST-STRESS-MK4 Know the ECG criteria indicative of an ischemic stress test response.X

L-TEST-STRESS-MK5 Know the normal and abnormal heart rate, rhythm, and blood pressureresponses to graded exercise and recovery.

X

L-TEST-STRESS-MK6 Know the influence of baseline ECG abnormalities and medications on theECG response to exercise.

X

L-TEST-STRESS-MK7 Know the exercise capacity, ECG and hemodynamic findings indicating astrongly positive test or adverse prognosis.

X

L-TEST-STRESS-MK8 Know the indications and criteria for stopping a test before the target heartrate is reached.

X

L-TEST-STRESS-MK9 Know the role of exercise testing in the evaluation of patients with cardiacarrhythmias and the significance of exercise-induced arrhythmias.

X

L-TEST-STRESS-MK10 Know the use of exercise testing in special groups (e.g., women,asymptomatic patients, and patients who have sustained myocardialinfarction or a recent acute coronary syndrome).

X

L-TEST-STRESS-MK11 Know the use of, precautions for, and contraindications to exercise testing inpatients with valvular and myocardial diseases.

X

L-TEST-STRESS-MK12 Know the role of exercise ECG testing in the evaluation of geneticcardiovascular conditions (e.g., long QT syndrome and hypertrophiccardiomyopathy).

X

L-TEST-STRESS-MK13 Know the indications for incorporating echocardiographic, radionuclideperfusion, and magnetic resonance imaging in stress testing.

X

L-TEST-STRESS-MK14 Know the indications for selection of exercise versus pharmacologic testing.X

L-TEST-STRESS-MK15 Know the indications for cardiopulmonary exercise testing.X

L-TEST-STRESS-MK16 Know the roles of exercise testing in physical activity counseling andexercise prescription in patients with cardiovascular disease.

X

L-TEST-STRESS-MK17 Know the role of exercise testing with measurement of ankle-brachial indicesin the evaluation of patients with known or suspected peripheral arterydisease.

X


Practice

Focused

L-TEST-STRESS-PC1 Skills to select appropriate exercise test modalities and protocols for diverse

patient types and clinical settings and itegrate the findings in patientevaluation and management.

X

L-TEST-STRESS-PC2 Skill to safely perform appropriate heart–rate-limited and maximal or near-maximal treadmill exercise tests.

X

L-TEST-STRESS-PC3 Skill to integrate exertional symptoms and capacity, ECG findings, andhemodynamic response in cardiovascular risk assessment and management.

X

Skill ili d f i i i d l i i


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Table 8. Echocardiography Lifelong Learning Competencies


Cardiologists

Selected

Cardiologists

Based onPractice

Focus

L-IMAG-ECHO-MK1 Know the physical principles of ultrasound and the instrumentation used to

obtain echocardiographic images.

X

L-IMAG-ECHO-MK2 Know the indications for and limitations of M-mode, 2-dimensional, and 3-dimensional transthoracic echocardiography, Doppler echocardiography,color flow imaging, transesophageal echocardiography, tissue Doppler, andcontrast echocardiography.

X

L-IMAG-ECHO-MK3 Know the potential artifacts that may confound the echocardiographicexamination.

X

L-IMAG-ECHO-MK4 Know the standard views included in a comprehensive transthoracicechocardiographic examination.

X

L-IMAG-ECHO-MK5 Know the methods to evaluate cardiac chamber sizes, left and rightventricular systolic and diastolic function, and hemodynamics byechocardiography.

X

L-IMAG-ECHO-MK6 Know the characteristic echocardiographic findings associated withcardiomyopathies and heart failure.

X

L-IMAG-ECHO-MK7 Know the indications for and characteristic findings of echocardiography inpatients with native valvular heart diseases and prosthetic heart valves,including endocarditis and its complications.

X

L-IMAG-ECHO-MK8 Know the characteristic echocardiographic findings associated with

myocardial ischemia and infarction and the structural complications ofmyocardial infarction.

X

L-IMAG-ECHO-MK9 Know the characteristic echocardiographic findings associated withpericardial effusion and tamponade.

X

L-IMAG-ECHO-MK10 Know the characteristic echocardiographic findings associated withpericardial constriction.

X

L-IMAG-ECHO-MK11 Know the characteristic echocardiographic findings characteristic of simpleadult congenital heart disease.

X

L-IMAG-ECHO-MK12 Know the characteristic echocardiographic findings of cardiac masses. X

L-IMAG-ECHO-MK13 Know the characteristic echocardiographic findings of thoracic aorticaneurysm and dissection.

X

L-IMAG-ECHO-MK14 Know the characteristic echocardiographic findings associated withpulmonary hypertension and right ventricular dysfunction and enlargement.

X

L-IMAG-ECHO-MK15 Know the characteristic echocardiographic findings associated with systemicdiseases involving the heart including amyloidosis

X


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L-IMAG-ECHO-MK22 Know the indications for stress echocardiography and the appropriateselection of exercise versus pharmacologic modalities.

X

Patient Care and Procedural SkillAll

Practice

Focused

L-IMAG-ECHO-PC1 Skill to review echocardiographic images and integrate the findings inpatient evaluation and management.*

X

L-IMAG-ECHO-PC2 Skill to perform and interpret a transthoracic echocardiographicexamination.

X

L-IMAG-ECHO-PC3 Skill to perform and interpret a transesophageal echocardiographicexamination.

X

L-IMAG-ECHO-PC4 Skill to perform and interpret stress echocardiography. X

L-IMAG-ECHO-PC5 Skill to perform and interpret basic 3-dimensional echocardiography. X

L-IMAG-ECHO-PC6 Skill to perform and interpret contrast echocardiography. X

L-IMAG-ECHO-PC7 Skill to identify and manage complications of stress, contrast, andtransesophageal echocardiography.

X

L-IMAG-ECHO-PC8 Skill to incorporate resting and stress hemodynamic information in theevaluation and management of patients with complex valvular heart diseaseor hypertrophic cardiomyopathy.

X

*In this document, “skill to review” refers to the ability to evaluate echocardiographic images during the course of patient care andintegrate echocardiographic information with other clinical data in patient management. It does not imply the formal interpretation andreporting of echocardiographic studies.

Table 9. Nuclear Cardiology Lifelong Learning Competencies


Cardiologists

SelectedCardiologists

Based on

Practice

Focus

L-IMAG-NC-MK1 Know the indications for and limitations of radionuclide imaging in theassessment of patients with myocardial ischemia or viability andventricular dysfunction.

X

L-IMAG-NC-MK2 Know the indications for myocardial perfusion imaging and theappropriate selection of exercise versus pharmacologic stressmodalities.

X

L-IMAG-NC-MK3 Know the principles of radiation safety and methods to minimize

radiation exposure to patients, operators, and staff.

X

L-IMAG-NC-MK4 Know the indications, contraindications, and limitations ofradionuclide imaging in the context of the pretest likelihood of diseaseand the predictive value of positive and negative tests.

X

L-IMAG-NC-MK5 Know the principles of single-photon emission computed tomographyand planar radionuclide ventriculography, including image acquisitionand display and the standard tomographic planes and views.

X


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Practice

Focused

L-IMAG-NC-PC1 Skills to select appropriate imaging studies and integrate the findingsin patient evaluation and management.

X

L-IMAG-NC-PC2 Skill to discern high-risk findings on stress testing. X

L-IMAG-NC-PC3 Skills to perform and interpret gated stress-rest perfusion studies. X

L-IMAG-NC-PC4 Skills to perform and interpret radionuclide ventriculography. X

Table 10. Cardiovascular Computed Tomography Lifelong Learning Competencies


Cardiologists

Selected

CardiologistsBased on

Practice

Focus L-IMAG-CCT-MK1 Know the technology and physics of cardiovascular computed

tomography.X

L-IMAG-CCT-MK2 Know the appropriate indications for and radiation-associated risks of

cardiovascular computed tomography for screening or evaluatingsymptoms in patients with known or suspected cardiac diseases and thestrategies to minimize exposure of patients, operators, and staff.

X

L-IMAG-CCT-MK3 Know the safety measures applicable to cardiovascular computedtomography, including strategies to minimize exposure of patients,operators, and staff to radiation.

X

L-IMAG-CCT-MK4 Know the potential adverse effects of iodinated contrast agents used incardiovascular computed tomography and approaches to preventing andtreating complications.

X

L-IMAG-CCT-MK5 Know the indications and protocols for and contraindications toadministration of beta-adrenergic blocking drugs and nitroglycerin inconjunction with cardiovascular computed tomography.

X

L-IMAG-CCT-MK6 Know the principles of acquisition, processing, and reconstruction ofcardiovascular computed tomographic images.

X

L-IMAG-CCT-MK7 Know the principles of quantitative coronary artery calcium scoring. X

L-IMAG-CCT-MK8 Know the cardiovascular computed tomographic imaging findings inpatients with normal chest anatomy, cardiac chambers, great vessels,coronary arteries and veins, and common variants.

X

L-IMAG-CCT-MK9 Know the characteristic cardiovascular computed tomographic imagingfindings associated with coronary atherosclerosis, including plaquemorphology and assessment of stenosis severity.

X

L-IMAG-CCT-MK10 Know the characteristic cardiovascular computed tomographic imagingfindings in patients with anomalous coronary arteries and other commoncongenital anomalies.

X

L-IMAG-CCT-MK11 Know the characteristic cardiovascular computed tomographic imaging X


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L-IMAG-CCT-MK17 Know the characteristic cardiovascular computed tomographic imagingfindings in patients with pulmonary embolism and primary and acquiredpulmonary vascular diseases.

X

L-IMAG-CCT-MK18 Know the characteristic cardiovascular computed tomographic imagingfindings that define the anatomy of the left atrium, left atrial appendage,and pulmonary veins in patients undergoing catheter-based proceduresfor atrial fibrillation.

X


Practice

Focused

L-IMAG-CCT-PC1 Skill to appropriately refer and prepare patients with known or suspectedcardiovascular disease for cardiovascular computed tomographic imagingand apply the findings in clinical evaluation and management.

X

L-IMAG-CCT-PC2 Skill to diagnose and manage adverse reactions to radiographic contrastand beta blockers that may arise during cardiovascular computedtomographic imaging.

X

L-IMAG-CCT-PC3 Skill to independently perform and interpret cardiovascular computedtomographic imaging.

X

Table 11. Cardiovascular Magnetic Resonance Lifelong Learning Competencies


Cardiologists

Selected

Cardiologists

Based on

PracticeFocus

L-IMAG-CMR-MK1 Know the imaging technology and associated physics of cardiovascularmagnetic resonance imaging.

X

L-IMAG-CMR-MK2 Know the indications for cardiovascular magnetic resonance imaging atrest and in response to pharmacological stress in patients with known orsuspected ischemic heart disease.

X

L-IMAG-CMR-MK3 Know the indications for, contraindications to, and potential side effectsof gadolinium-based contrast agents in cardiovascular magneticresonance imaging.

X

L-IMAG-CMR-MK4 Know the risks of and contraindications to cardiovascular magneticresonance imaging.

X

L-IMAG-CMR-MK5 Know the characteristic cardiovascular magnetic resonance imagingfindings associated with ischemic heart disease.

X

L-IMAG-CMR-MK6 Know the characteristic cardiovascular magnetic resonance imagingfindings associated with hypertrophic and other cardiomyopathies andmyocarditis.

X

L-IMAG-CMR-MK7 Know the characteristic cardiovascular magnetic resonance imagingfindings associated with pericardial diseases.

X

L-IMAG-CMR-MK8 Know the characteristic cardiovascular magnetic resonance imaging X


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PracticeFocused

L-IMAG-CMR-PC1 Skills to appropriately order cardiovascular magnetic resonance imagingand integrate the results in patient evaluation and management.

X

L-IMAG-CMR-PC2 Skill to interpret cardiovascular magnetic resonance tissuecharacterization (late gadolinium enhancement) to distinguish theetiology of cardiomyopathy and acute myocardial injury.

X

L-IMAG-CMR-PC3 Skill to interpret regional and global left and right ventricular wallmotion and ejection fraction by magnetic resonance imaging.

X

L-IMAG-CMR-PC4 Skill to interpret magnetic resonance images in patients with diseases ofthe aorta (e.g., intramural hematoma, dissection, coarctation, andaneurysm).

X

L-IMAG-CMR-PC5 Skill to identify and characterize myocardial masses by magneticresonance imaging.

X

L-IMAG-CMR-PC6 Skill to identify and characterize pericardial diseases by magneticresonance imaging.

X

L-IMAG-CMR-PC7 Skill to identify and characterize adult congenital heart diseases bymagnetic resonance imaging.

X

L-IMAG-CMR-PC8 Skills to perform and interpret cardiovascular magnetic resonance stresstesting. X

Table 12. Invasive Cardiology Lifelong Learning Competencies


Cardiologists


Based on

Practice

Focus L-INV/INT-MK1 Know the indications for, contraindications to and potentialcomplications of cardiac catheterization for assessment of patientswith coronary, valvular, myocardial, and basic adult congenital heartdiseases.

X

L-INV/INT-MK2 Know the principles of radiation safety in the cardiac catheterizationlaboratory, including strategies to minimize exposure of patients,operators, and staff.

X

L-INV/INT-MK3 Know the use and complications of radiographic contrast media andthe measures available for renal protection in the cardiac

catheterization laboratory.

X

L-INV/INT-MK4 Know the indications for, and clinical pharmacology of, antiplateletand anticoagulant drugs, vasopressor and vasodilator agents, andinotropic drugs used in the cardiac catheterization laboratory.

X

L-INV/INT-MK5 Know the principles of waveforms, pressure, flow, resistance, andcardiac output measurements obtained by cardiac catheterization.

X


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L-INV/INT-MK11 Know the characteristic angiographic features associated withperipheral artery disease and the methods available to assess itsanatomic and physiologic severity.

X

L-INV/INT-MK12 Know the indications for and potential complications of percutaneousinterventions for coronary and peripheral artery as well as valvularand nonvalvular structural heart disease.

X

L-INV/INT-MK13 Know the indications for, contraindications to, and potentialcomplications of endomyocardial biopsy.

X

L-INV/INT-MK14 Know the indications for, contraindications to, and potential

complications of pericardiocentesis.

X

L-INV/INT-MK15 Know the physiologic basis and indications for mechanical circulatorysupport devices.

X

L-INV/INT-MK16 Know the indications for and complications of vascular access andclosure strategies and devices.

X

L-INV-INT-MK17 Know the indications for fluid challenge, vasodilator testing, and post-exercise measurements during right heart catheterization.

X


PracticeFocused

L-INV/INT-PC1 Skills to conduct preprocedural evaluation for, assess appropriatenessof, obtain informed consent from, and plan procedure strategy forpatients undergoing cardiac catheterization and angiography.

X

L-INV/INT-PC2 Skills to perform venous and arterial access and obtain hemostasis inpatients undergoing cardiac catheterization and angiography.

X

L-INV/INT-PC3 Skill to perform right heart catheterization. X

L-INV/INT-PC4 Skill to integrate hemodynamic, ventriculographic, and angiographicdata in patient evaluation and management.

X

L-INV/INT-PC5 Skill to coordinate post-procedural management for patientsundergoing cardiac catheterization, including recognition andtreatment of complications.

X

L-INV/INT-PC6 Skill to perform endomyocardial biopsy. X

L-INV/INT-PC7 Skill to perform elective pericardiocentesis. X

L-INV/INT-PC8 Skills to perform diagnostic left heart catheterization, contrastventriculography, and coronary angiography.

X

L-INV/INT-PC9 Skill to place an intra-aortic balloon pump. X

Table 13. Stable Ischemic Heart Disease Lifelong Learning


Cardiologists

Selected

Cardiologists

Based onPractice

Focus

L-ISCHEM-MK1 Know the epidemiology, pathophysiology, and natural history of X


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L-ISCHEM-MK6 Know the medical conditions that can provoke or exacerbate anginapectoris.

X

L-ISCHEM-MK7 Know the differential diagnosis and prognosis of myocardial ischemiain patients with nonobstructive coronary disease.

X

L-ISCHEM-MK8 Know the characteristic electrocardiographic features associated withmyocardial ischemia.

X

L-ISCHEM-MK9 Know the indications for, contraindications to, and limitations ofnoninvasive testing in the context of the pretest likelihood of diseaseand the predictive value of positive and negative tests in the evaluation

of patients with known or suspected coronary disease.

X

L-ISCHEM-MK10 Know the role of noninvasive testing in risk assessment, including theclinical, functional capacity, ECG, and hemodynamic findings on stresstesting indicative of advanced coronary disease or high-risk states.

X

L-ISCHEM-MK11 Know the lifestyle, activity, and exercise recommendations and riskfactor treatment targets for patients with stable ischemic heart disease.

X

L-ISCHEM-MK12 Know the indications for, contraindications to, and clinicalpharmacology of medications used for management of patients withstable ischemic heart disease.

X

L-ISCHEM-MK13 Know the significance of left ventricular systolic and diastolic functionin the management of patients with ischemic heart disease.

X

L-ISCHEM-MK14 Know the indications for, limitations of, and risks associated withcoronary angiography in patients with known or suspected ischemicheart disease.

X

L-ISCHEM-MK15 Know the findings at cardiac catheterization indicatinghemodynamically significant coronary artery obstruction and theangiographic features indicative of high-risk conditions.

X

L-ISCHEM-MK16 Know the treatment options for patients with ischemic heart disease and

symptoms refractory to pharmacologic therapy.

X

L-ISCHEM-MK17 Know the indications for and risks and benefits of percutaneous orsurgical revascularization compared with medical therapy in patientswith stable ischemic heart disease.

X

L-ISCHEM-MK18 Know the indications for noninvasive and invasive evaluation followingrevascularization in patients with ischemic heart disease.

X


Practice

Focused

L-ISCHEM-PC1 Skills to obtain and utilize the clinical history, physical examination,and ECG findings in patients with chest pain to establish the probability

of symptomatic coronary disease.

X

L-ISCHEM-PC2 Skill to distinguish stable from unstable coronary syndromes. X

L-ISCHEM-PC3 Skill to select evidence-based, cost-effective noninvasive testingstrategies for diagnosis and risk assessment in patients with chest pain.

X

L-ISCHEM-PC4 Skill to integrate data from noninvasive testing in the management of X


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L-ISCHEM-PC10 Skills to provide preoperative risk assessment and perioperativemanagement for patients with cardiovascular disease undergoing non-cardiac surgery.

X

L-ISCHEM-PC11 Skill to perform diagnostic cardiac catheterization and coronaryangiography.

X

Table 14. Acute Coronary Syndromes Lifelong Learning Competencies


Cardiologists


Based on

PracticeFocus

L-ACS-MK1 Know the epidemiology, etiology, pathophysiology, and natural historyof acute coronary syndromes, including the roles of plaque rupture,erosion, platelet activation, vasospasm, and thrombosis.

X

L-ACS-MK2 Know the disorders that can simulate or mask acute coronarysyndromes.

X

L-ACS-MK3 Know the risk assessment tools applicable to patients with acutecoronary syndromes.

X

L-ACS-MK4 Know the indications for, clinical pharmacology of, andcontraindications to antiplatelet, anticoagulant, and other pharmacologictherapies in patients with ischemic heart disease.

X

L-ACS-MK5 Know the principles and timing of rehabilitation and secondaryprevention measures for patients with acute coronary syndromes.

X

ST Elevation Myocardial Infarction (STEMI):

L-ACS-MK6 Know the characteristic symptoms, physical findings, ECG patterns,and biomarker findings in patients with STEMI.

X

L-ACS-MK7 Know the effects and time course of ischemic injury on ventricularfunction and remodeling in patients with STEMI.

X

L-ACS-MK8 Know the potential hemodynamic complications (includinghypotension, low cardiac output, heart failure, and shock) in patientswith STEMI.

X

L-ACS-MK9 Know the potential arrhythmia and conduction complications associatedwith STEMI.

X

L-ACS-MK10 Know the potential mechanical complications (including papillarymuscle rupture and myocardial rupture) associated with STEMI. X

L-ACS-MK11 Know the characteristic clinical findings and potential complications ofright ventricular infarction.

X

L-ACS-MK12 Know the indications for, contraindications to, and risks of reperfusiontherapies and the clinical, ECG, and angiographic signs of reperfusionin patients with STEMI.

X


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Patient Care and Procedural Skills AllPracticeFocused

L-ACS-PC1 Skills to evaluate patients with STEMI and initiate appropriatereperfusion therapy within guideline-recommended timeframes.

X

L-ACS-PC2 Skill to employ appropriate antiplatelet, anticoagulant, and otherpharmacologic therapies for patients with acute coronary syndromes.

X

L-ACS-PC3 Skills to identify the cause of and treat hemodynamic disturbances(including hypotension, low cardiac output, heart failure, acutepulmonary edema, and shock) in patients with acute coronary

syndromes.

X

L-ACS-PC4 Skills to identify and treat arrhythmias and conduction disturbances inpatients with acute coronary syndromes.

X

L-ACS-PC5 Skill to diagnose mechanical complications (including papillary musclerupture and myocardial rupture) in patients with acute coronarysyndromes.

X

L-ACS-PC6 Skill to implement mechanical support for patients with complicationsof acute coronary syndromes (including papillary muscle rupture andmyocardial rupture).

X

L-ACS-PC7 Skills to diagnose and treat patients with right ventricular infarction. X

L-ACS-PC8 Skills to assess ventricular function in patients with acute coronarysyndromes and integrate this information in clinical management.

X

L-ACS-PC9 Skills to assess risk in patients with NSTE-ACS, establish an optimalmedical regimen, and identify candidates for invasive evaluation andtreatment.

X

L-ACS-PC10 Skill to integrate invasive hemodynamic data and angiographic findingsin the management of patients with acute coronary syndromes.

X

L-ACS-PC11 Skill to perform and interpret the results of coronary angiography inpatients with acute coronary syndromes.

X

L-ACS-PC12 Skill to insert intra-arterial and pulmonary artery catheters and integratethe findings in the management of patients with acute coronarysyndromes.

X

L-ACS-PC13 Skill to identify patients with acute coronary syndromes who benefitfrom mechanical circulatory support.

X

L-ACS-PC14 Skill to initiate and appropriately escalate therapies for secondaryprevention in patients with acute coronary syndromes.

X

Table 15. Valvular Heart Disease Lifelong Learning Competencies


Cardiologists

Selected

Cardiologists

Based onPractice

Focus


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L-VALV-MK7 Know the indications for mitral valve intervention in patients withprimary and secondary mitral regurgitation.

X

L-VALV-MK8 Know the indications for and characteristic findings ofechocardiography during evaluation and follow-up of patients withnative and prosthetic valve diseases, including endocarditis and itscomplications.

X

L-VALV-MK9 Know the role of stress testing in assessment of patients with valvularheart disease.

X

L-VALV-MK10 Know the indications for MR and CT imaging in the assessment of

patients with valvular heart disease.

X

L-VALV-MK11 Know the indications for and characteristic findings at cardiaccatheterization in patients with valvular heart disease.

X

L-VALV-MK12 Know the indications for and clinical pharmacology of drugs used fortreatment of patients with valvular heart disease and prosthetic heartvalves, including anticoagulation and antibiotic prophylaxis.

X

L-VALV-MK13 Know the effects of arrhythmias, particularly atrial fibrillation, on theclinical manifestations of, risks of complications in, and management ofpatients with valvular heart disease.

X

L-VALV-MK14 Know the indications for and expected outcomes and potentialcomplications of surgical therapy for patients with valvular heartdisease, including repair versus replacement and selection of prostheses.

X

L-VALV-MK15 Know the indications for and expected outcomes and potentialcomplications of transcatheter therapy for patients with valvular heartdisease.

X

L-VALV-MK16 Know the etiology, natural history, physical findings, differentialdiagnosis, complications, and treatment of patients with native andprosthetic valve endocarditis.

X

L-VALV-MK17 Know the effects of pregnancy on the clinical manifestations of valvularheart disease (native and prosthetic) and implications for patientmanagement.

X

Patient Care and Procedural Skills AllPractice

Focused

L-VALV-PC1 Skill to identify the cardinal clinical ECG and chest X-ray findings inpatients with valvular heart disease.

X

L-VALV-PC2 Skill to distinguish innocent from pathologic heart murmurs. X

L-VALV-PC3 Skill to manage patients with combined valvular and coronary heart

disease.

X

L-VALV-PC4 Skill to select appropriate testing, including exercise testing, andintegrate results with clinical findings in the evaluation andmanagement of patients with valvular heart disease.

X

L-VALV-PC5 Skill to distinguish aortic stenosis from hypertrophic obstructivecardiomyopathy and other causes of left ventricular outflow tract

X


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Table 16. Heart Failure Lifelong Learning Competencies


Cardiologists

Selected

Cardiologists

Based on

PracticeFocus

L-HF-MK1 Know the pathophysiology, differential diagnosis, stages, and naturalhistory of heart failure.

X

L-HF-MK2 Know the effects of heart failure on pulmonary, renal, and hepatic

function, the nutritional and metabolic implications of heart failure,and the interactions of heart failure with other systemic diseases.

X

L-HF-MK3 Know the characteristic history and physical examination findings,and their limitations in the evaluation of patients with heart failure.

X

L-HF-MK4 Know the pathophysiology and cardinal clinical findings ofpulmonary arterial hypertension.

X

L-HF-MK5 Know the indications for, contraindications to, clinical pharmacology,and potential adverse effects of drugs used to treat patients with heartfailure.

X

L-HF-MK6 Know the management of cardiac arrhythmias and conductiondisturbances in patients with heart failure, including the indicationsfor and risks of implantable cardioverter-defibrillator and cardiacresynchronization devices.

X

L-HF-MK7 Know the indications for referral of patients with advanced heartfailure for mechanical support devices and cardiac transplantation.

X

L-HF-MK8 Know the pathophysiology of heart failure at the molecular, cellular,and organ levels, with emphasis on the roles of neurohormonalactivation and left ventricular remodeling in disease progression.

X

L-HF-MK9 Know the diagnostic and management strategies for patients withheart failure due to nonischemic forms of heart disease, includinginfiltrative and restrictive cardiomyopathies, inheritedcardiomyopathies, and cardiomyopathies associated with pregnancyand cancer chemotherapy.

X

L-HF-MK10 Know the management strategies and complications of therapy forheart failure in special populations, including patients with congenitalheart disease and chronic pulmonary disease.

X

L-HF-MK11 Know the indications for, contraindications to, and clinicalpharmacology of intravenous vasoactive and inotropic drugs used for

cardiovascular support in patients with advanced or/refractory heartfailure.

X

L-HF-MK12 Know the indications for, contraindications to, and potentialcomplications of endomyocardial biopsy.

X

L-HF-MK13 Know the types of and indications for mechanical circulatory supportin patients with severe heart failure.

X


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L-HF-PC3 Skill to manage comorbidities in patients with heart failure. XL-HF-PC4 Skill to use the clinical history and findings on physical examination

to accurately assess volume status and systemic perfusion in patientswith heart failure.

X

L-HF-PC5 Skill to integrate hemodynamic measurements and data fromphysiological monitoring in the management of patients withdecompensated heart failure.

X

L-HF-PC6 Skills to evaluate and treat cardiac arrhythmias and conductiondisturbances in patient with heart failure and identify candidates for

implantable cardioverter-defibrillators, cardiac resynchronizationtherapy, or arrhythmia ablation procedures.

X

L-HF-PC7 Skill to manage depression and anxiety as part of the overall care ofpatients with heart failure and appropriately seek psychiatricconsultation.

X

L-HF-PC8 Skills to effectively utilize an interdisciplinary approach to monitorthe progress of ambulatory patients with heart failure, maintainstability, and avoid preventable hospitalization.

X

L-HF-PC9 Skill to select and appropriately refer patients with heart failure for

advanced therapies, including cardiac transplantation.

X

L-HF-PC10 Skill to identify appropriate candidates with advanced heart failure forpalliative and hospice care.

X

L-HF-PC11 Skill to interpret the results of cardiopulmonary exercise testing andincorporate physical activity and exercise recommendations into themanagement of patients with heart failure.

X

L-HF-PC12 Skill to integrate imaging data into the evaluation and management ofpatients with heart failure.

X

L-HF-PC13 Skill to evaluate and manage patients with refractory heart failure. X

L-HF-PC14 Skill to integrate hemodynamic and physiologic monitoring data inthe management of complex patients with advanced heart failure. X

L-HF-PC15 Skill to perform invasive hemodynamic monitoring in patients withheart failure.

X

L-HF-PC16 Skill to appropriately implement anti-arrhythmic drug therapy,implantable cardioverter-defibrillators, cardiac resynchronizationdevices, and substrate ablation procedures in patients with heartfailure.

X

L-HF-PC17 Skill to identify and manage patients with heart failure who require

transition from hospital to home or to a care facility while receivingintravenous infusion of inotropic or vasoactive agents.

X

Table 17. Pericardial Disease Lifelong Learning Competencies


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L-PERI-MK6 Know the indications for, clinical pharmacology of, and potentialtoxicity of drugs used for treatment of acute and relapsing pericarditis.

X

L-PERI-MK7 Know the effects of pericardial diseases on other organ systems. X

L-PERI-MK8 Know the anatomy and structural abnormalities of the pericardium,including pericardial cysts and congenital absence of the pericardium.

X

L-PERI-MK9 Know the indications for and characteristic findings of imaging studiesused to evaluate patients with pericardial diseases.

X

L-PERI-MK10 Know the indications for, expected outcomes of, and potentialcomplications of surgery in patients with pericardial diseases.

X


PracticeFocused

L-PERI-PC1 Skill to clinically evaluate and manage patients with acute and relapsingpericarditis.

X

L-PERI-PC2 Skill to identify and elicit the cardinal physical findings of pericardialeffusion, tamponade, and chronic constrictive pericarditis.

X

L-PERI-PC3 Skill to identify cardinal physical findings and evaluate and managepatients with constrictive pericarditis.

X

L-PERI-PC4 Skill to appropriately select and incorporate data from laboratory testing

and noninvasive imaging in the management of patients with diseases ofthe pericardium.

X

L-PERI-PC5 Skill to perform elective pericardiocentesis. X

L-PERI-PC6 Skill to differentiate constrictive pericarditis from restrictive cardiacdisease.

X

L-PERI-PC7 Skill to identify patients with pericardial disease who are candidates forcardiac catheterization in the evaluation of pericardial disease.

X

L-PERI-PC8 Skill to identify and appropriately refer patients with constrictivepericarditis who are candidates for cardiac surgery.

X

Table 18. Vascular Medicine Lifelong Learning Competencies


Cardiologists


Based on

PracticeFocus

L-VASC-MK1 Know the causes, pathophysiology and natural history of aortic,cerebrovascular, renal, mesenteric, and extremity peripheral arterydiseases.

X

L-VASC-MK2 Know the cardinal symptoms and physical findings of aortic,cerebrovascular, renal, mesenteric, and extremity peripheral arterydiseases.

X

L-VASC-MK3 Know the indications for duplex ultrasonography of the carotid, X


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L-VASC-MK8 Know the indications for use of noninvasive imaging in patients at riskfor or with known abdominal aortic aneurysm.

X

L-VASC-MK9 Know the indications for risks and expected outcomes of surgical andendovascular interventions for patients with abdominal aorticaneurysmal disease.

X

L-VASC-MK10 Know the causes, pathophysiology and natural history of deep veinthrombosis and pulmonary embolism.

X

L-VASC-MK11 Know the cardinal symptoms and physical findings of deep veinthrombosis and pulmonary embolism.

X

L-VASC-MK12 Know the cardinal symptoms, and physical signs of chronic venousinsufficiency and varicose veins.

X

L-VASC-MK13 Know the indications for, contraindications to, risks, clinicalpharmacology, and interactions of antithrombotic medications used fortherapy of venous thromboembolism (pulmonary embolism and deepvein thrombosis).

X

L-VASC-MK14 Know the indications for, contraindications to, risks, and expectedoutcomes of thrombolytic therapy for patients with venousthromboembolism.

X

L-VASC-MK15 Know the differentiating features of arterial, venous, and neurotrophicleg ulcers. X

L-VASC-MK16 Know the causes, cardinal findings, and treatment of lymphedema. X

L-VASC-MK17 Know the indications for laboratory testing for inherited and acquiredforms of thrombophilia.

X

L-VASC-MK18 Know the indications and laboratory tests for vasculitis. X


Practice

Focused

L-VASC-PC1 Skill to perform a comprehensive physical examination of the peripheralcirculation.

X

L-VASC-PC2 Skill to perform and interpret the results of physical examinationmaneuvers for detection of arterial compression syndromes (e.g.,thoracic outlet and popliteal artery entrapment syndromes).

X

L-VASC-PC3 Skill to measure the ankle-brachial index. X

L-VASC-PC4 Skill to interpret segmental limb blood pressure measurements, pulsevolume recordings, Doppler waveforms, and treadmill exercise testresults in patients with known or suspected peripheral artery disease.

X

L-VASC-PC5 Skill to interpret duplex ultrasound examinations of the extracranial

carotid arteries, peripheral arteries, abdominal aorta, renal andmesenteric arteries, and peripheral veins.

X

L-VASC-PC6 Skill to evaluate and manage patients with lower extremity peripheralartery disease.

X

L-VASC-PC7 Skill to evaluate and manage patients with extracranial carotid andvertebral artery disease.

X

L VASC PC8 Skill to coordinate management for patients with arterial access X


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Table 19. Cardiac Arrhythmias and Electrophysiology Lifelong Learning Competencies

Competency ID Medical Knowledge All Clinical

Cardiologists

Selected

Cardiologists

Based on

PracticeFocus

L-ARR-MK1 Know the mechanism and characteristics of normal sinus rhythm andsinus node dysfunction.

X

L-ARR-MK2 Know the pathophysiology, differential diagnosis, and approach tomanagement of patients with re-entrant tachycardia (atrioventricularnodal re-entrant tachycardia, atrioventricular reciprocating tachycardia),ectopic atrial tachycardias, and accelerated atrioventricular junctionalrhythm.

X

L-ARR-MK3 Know the pathophysiology, differential diagnosis, clinical significance,and approach to management of patients with atrial fibrillation and atrialflutter.

X

L-ARR-MK4 Know the risk factors for stroke and bleeding in patients with atrialfibrillation or atrial flutter and the indications for and use ofanticoagulant drugs.

X

L-ARR-MK5 Know the pathophysiology, differential diagnosis, clinical significance,and approach to management of patients with sustained and nonsustainedventricular tachyarrhythmias.

X

L-ARR-MK6 Know the pathophysiology and differential diagnosis of approaches to

risk stratification for, and management of survivors of cardiac arrest andsudden death.

X

L-ARR-MK7 Know the risk factors for syncope and sudden death in athletes andindividuals engaging in vigorous physical activity.

X

L-ARR-MK8 Know the types, mechanisms, differential diagnosis, clinical significance,and approach to management of patients with atrioventricular

X

L-VASC-PC13 Skill to evaluate and manage patients with venous thromboembolism. X

L-VASC-PC14 Skill to evaluate and manage patients with chronic peripheral venousdisorders, including varicose veins, and chronic venous insufficiency.

X

L-VASC-PC15 Skill to evaluate and manage patients with lymphedema. X

L-VASC-PC16 Skill to evaluate and manage patients with lower extremity ulcers. X

L-VASC-PC17 Skill to evaluate and manage patients with temperature-related vasculardisorders, including Raynaud’s phenomenon, acrocyanosis, pernio, anderythromelalgia.

X

L-VASC-PC18 Skill to evaluate and manage patients with uncommon vasculardisorders, including vascular compression syndromes, fibromusculardysplasia, and congenital vascular malformations.

X


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L-ARR-MK13 Know the indications for and limitations and complications of invasiveelectrophysiological testing in patients with known or suspected cardiacarrhythmias and the indications for and risks of catheter ablation.

X

L-ARR-MK14 Know the indications for and contraindications to implantation ofpermanent pacemakers, cardiac resynchronization devices, andcardioverter-defibrillators.

X

L-ARR-MK15 Know the pathophysiology, differential diagnosis, natural history, andapproach to management of patients with syncope.

X

L-ARR-MK16 Know the mechanisms, findings, clinical significance, and approach to

management of patients with ventricular pre-excitation.

X

L-ARR-MK17 Know the pathology and clinical significance of, and the approach toevaluation and management of patients with inherited causes of cardiacarrhythmias, including ion channel abnormalities and structural changesin the heart (including long QT syndrome, Brugada syndrome,arrhythmogenic right ventricular dysplasia, hypertrophic and dilatedcardiomyopathy, and myotonic dystrophy), and the role of genetictesting.

X

L-ARR-MK18 Know the indications for interrogation of implanted cardiac electronic

devices.

X

Patient Care and Procedural SkillAll

Practice

Focused

L-ARR-PC1 Skill to evaluate and manage patients with palpitation. X

L-ARR-PC2 Skill to evaluate and manage patients with syncope. X

L-ARR-PC3 Skill to evaluate and manage patients with supraventriculartachyarrhythmias.

X

L-ARR-PC4 Skill to evaluate and manage patients with atrial fibrillation and atrialflutter, including rate control, rhythm control, and anticoagulationstrategies.

X

L-ARR-PC5 Skill to evaluate and manage patients with wide-QRS tachycardia. XL-ARR-PC6 Skill to manage patients with nonsustained and sustained ventricular

arrhythmias.X

L-ARR-PC7 Skill to evaluate and manage patients with bradycardia and/or conductionblock.

X

L-ARR-PC8 Skill to perform electrical cardioversion. X

L-ARR-PC9 Skill to perform defibrillation. X

L-ARR-PC10 Skill to perform tilt-table testing. X

L-ARR-PC11 Skill to insert temporary transvenous pacemakers. X

L-ARR-PC12 Skill to select and appropriately refer patients for implantation ofpermanent pacemakers, cardioverter-defibrillators, or cardiacresynchronization devices.

X

L-ARR-PC13 Skill to integrate information from cardiac electrophysiologyconsultation, diagnostic electrophysiological procedures, and deviceinterrogation into the management of patients with cardiac

X


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L-ARR-PC18 Skill to evaluate and manage hospitalized survivors of cardiac arrest. XL-ARR-PC19 Skill to select appropriate ambulatory arrhythmia monitoring technology

and integrate the results in patient management.

X

Table 20. Critical Care Cardiology Lifelong Learning Competencies


Cardiologists


Based onPractice

Focus L-CCC-MK1 Know the pathophysiology, differential diagnosis, and characteristic

clinical, hemodynamic, radiographic, and laboratory findings ofcardiogenic, hypovolemic, septic, and mixed circulatory shock and thesystemic inflammatory response syndrome.

X

L-CCC-MK2 Know the indications for and characteristic findings of bedsidenoninvasive and invasive hemodynamic monitoring.

X

L-CCC-MK3 Know the indications for, contraindications to, and clinical pharmacology

of vasoactive and inotropic medications used to treat patients with heartfailure, hypotension, or shock.

X

L-CCC-MK4 Know the indications for, contraindications to, and clinical pharmacologyof anticoagulant, antiplatelet, and fibrinolytic agents.

X

L-CCC-MK5 Know the indications for, contraindications to, and clinical pharmacologyof agents used to treat patients with hypertensive urgencies andemergencies.

X

L-CCC-MK6 Know the indications for, contraindications to, and clinical pharmacology

of agents used to treat patients with pulmonary hypertension, includinginhalational agents.

X

L-CCC-MK7 Know the indications for, contraindications to, clinical pharmacology andpotential toxicity of antiarrhythmic drugs in the clinical care setting.

X

L-CCC-MK8 Know the indications for, contraindications to, and risks of catheter-basedinterventions for patients with supraventricular and ventriculararrhythmias.

X

L-CCC-MK9 Know the characteristic clinical, electrocardiographic, echocardiographic,and radiographic findings associated with pulmonary embolism, aorticdissection, pericardial tamponade, acute decompensated heart failure, andmyocardial infarction.

X

L-CCC-MK10 Know the indications for oxygen supplementation, noninvasive ventilation,endotracheal intubation, and mechanical ventilatory support for patientswith hypoxia and/or respiratory failure.

X

L CCC MK11 K h diff i l di i d h i i l b fi di X


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L-CCC-MK14 Know the principles of treatment of hypotension in patients withcardiogenic shock, hypertrophic obstructive cardiomyopathy, right ventricular infarction, massive pulmonary embolism, pericardialtamponade, and distributive shock.

X

L-CCC-MK15 Know the indications for immediate and delayed surgery in patients withaortic dissection.

X

L-CCC-MK16 Know the differential diagnosis of heart failure or shock following cardiactransplantation.

X

L-CCC-MK17 Know the prognostic factors used to assess patients with acute coronary

syndromes and advanced heart failure.

X

L-CCC-MK18 Know the risk factors for major bleeding in patients receivingantithrombotic medications.

X

L-CCC-MK19 Know the principles of post-resuscitation care and the indications forhypothermia.

X

Patient Care and Procedural Skill AllPracticeFocused

L-CCC-PC1 Skills to manage patients with acute myocardial infarction andassociated rhythm, conduction, hemodynamic, and mechanical

complications.

X

L-CCC-PC2 Skill to integrate findings from clinical, electrocardiographic, imaging,and hemodynamic assessments into the management of unstable cardiacpatients.

X

L-CCC-PC3 Skills to insert arterial, central venous, and pulmonary artery cathetersand temporary transvenous pacemakers.

X

L-CCC-PC4 Skill to coordinate renal replacement therapy in conjunction withnephrology consultants.

X

L-CCC-PC5 Skill to employ therapeutic hypothermia protocols in survivors of

cardiac arrest.

X

L-CCC-PC6 Skill to evaluate and manage patients with hemodynamic instabilityfollowing cardiac surgery.

X

L-CCC-PC7 Skills to evaluate and manage patients with supraventricular andventricular arrhythmias and conduction disturbances in unstable patientsin collaboration with electrophysiology consultants.

X

L-CCC-PC8 Skill to utilize vasopressor and inotropic therapy appropriately inpatients with various types of shock.

X

L-CCC-PC9 Skill to implement mechanical circulatory support in the management ofcritically ill patients. X

L-CCC-PC10 Skill to perform and lead cardiopulmonary resuscitation. X

L-CCC-PC11 Skill to recognize the clinical signs of pericardial tamponade. X

L-CCC-PC12 Skill to perform elective pericardiocentesis. X


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Table 21. Adults With Simple Congenital Heart Disease [Atrial Septal Defects, Ventricular SeptalDefects, Patent Ductus Arteriosus, Pulmonary Stenosis, Bicuspid Aortic Valve, Coarctation] Lifelong

Learning Competencies


Cardiologists

Selected

Cardiologists

Based on

Practice

Focus

L-ACHD(S)-MK1 Know the anatomy, pathophysiology, associated conditions, and naturalhistory of defects in cardiac septation, including patent foramen ovale,atrial septal aneurysm, atrial septal defects (primum, secundum, andsinus venosus), and ventricular septal defects.

X

L-ACHD(S)-MK2 Know the anatomy, pathophysiology, associated lesions, and naturalhistory of aortic valve and aortic defects including bicuspid valve, sinusof Valsalva aneurysm, pulmonic stenosis, coarctation, and patent ductusarteriosus.

X

L-ACHD(S)-MK3 Know the pathophysiology of and risks associated with pulmonaryarterial hypertension in adults with congenital heart disease.

X

L-ACHD(S)-MK4 Know the potential risks associated with noncardiac surgery, pregnancy,contraception, and exercise in adults with congenital heart disease andpulmonary arterial hypertension.

X

L-ACHD(S)-MK5 Know the reproductive and genetic implications of adult congenital heartdisease for the patient, fetus and offspring.

X

L-ACHD(S)-MK6 Know the indications for patient referral to an adult congenital heartdisease center.

X

L-ACHD(S)-MK7 Know the characteristic symptoms, signs, and ECG and chest X-rayfindings associated with simple congenital heart diseases in adults.

X

L-ACHD(S)-MK8 Know the indications for noninvasive and invasive testing in theevaluation of adult patients with simple congenital heart disease.

X

L-ACHD(S)-MK9 Know the indications for and contraindications to surgical andpercutaneous interventions for congenital heart disease in adults.

X

L-ACHD(S)-MK10 Know the indications for endocarditis prophylaxis

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